McDonald criteria

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Animation showing dissemination of multiple sclerosis lesions in time and space as demonstrated by monthly MRI studies along a year

The McDonald criteria are diagnostic criteria for multiple sclerosis (MS). These criteria are named after neurologist W. Ian McDonald. In April 2001, an international panel in association with the National Multiple Sclerosis Society (NMSS) of America recommended revised diagnostic criteria for MS. They have undergone revisions in 2005[1] and 2010.[2] These new criteria intended to replace the Poser criteria and the older Schumacher criteria. They discourage the previously used Poser terms such as "clinically definite" and "probable MS", and propose as diagnostic either "MS", "possible MS", or "not MS".[3]

The McDonald criteria maintained a scheme for diagnosing MS based solely on clinical grounds but also proposed for the first time that when clinical evidence is lacking, magnetic resonance imaging (MRI) findings can serve as surrogates for dissemination in space (DIS) and/or time (DIT) to diagnose MS.[4] The criteria try to prove the existence of demyelinating lesions, by image or by their effects, showing that they occur in different areas of the nervous system (DIS) and that they accumulate over time (DIT). The McDonald criteria facilitate the diagnosis of MS in patients who present with their first demyelinating attack and significantly increase the sensitivity for diagnosing MS without compromising the specificity.[4]

The McDonald criteria for the diagnosis of multiple sclerosis were revised first in 2005 to clarify exactly what is meant by an "attack", "dissemination" and a "positive MRI", etc.[1] Later they were revised again in 2010.

McDonald's criteria are the standard clinical case definition for MS and the 2010 version is regarded as the gold standard test for MS diagnosis.[citation needed]

Diagnostic Criteria[edit]

Clinical Presentation Additional Data Needed
* 2 or more attacks (relapses)
* 2 or more objective clinical lesions
None; clinical evidence will suffice (additional evidence desirable but must be consistent with MS)
* 2 or more attacks
* 1 objective clinical lesion
Dissemination in space, demonstrated by:
* MRI
* or a positive (cerebrospinal fluid) CSF and 2 or more MRI lesions consistent with MS
* or further clinical attack involving different site
* 1 attack
* 2 or more objective clinical lesions
Dissemination in time, demonstrated by:
* MRI
* or second clinical attack
* 1 attack
* 1 objective clinical lesion
(monosymptomatic presentation)
Dissemination in space demonstrated by:
* MRI
* or positive CSF and 2 or more MRI lesions consistent with MS
and
Dissemination in time demonstrated by:
* MRI
* or second clinical attack
Insidious neurological progression
suggestive of MS
(primary progressive MS)
One year of disease progression (retrospectively or prospectively determined) and

Two of the following:

a. Positive brain MRI (nine T2 lesions or four or more T2 lesions with positive VEP)
b. Positive spinal cord MRI (two focal T2 lesions)
c. Positive CSF

They discourage the previously used terms such as "clinically definite" and "probable MS", and propose as diagnostic either "MS", "possible MS", or "not MS".[3]

Criticism[edit]

Pathology is generally regarded as the gold standard in defining different forms of inflammatory demyelinating diseases.[5]

Specificity of the McDonald criteria is low due to the fact that the nature of the lesions is not considered, but only their dissemination. None of the criteria are MS-specific. In order to reduce false positives, McDonald et al. propose that their criteria should be applied only after any other disease has been ruled out.[3] In 2008 a consensus was developed for differential diagnosis.[6]

Another criticism of the McDonald criteria is that the definition of "lesions typical of MS" is unclear; a 2013 review identified the following characteristics: specific cell morphology shown by hematoxylin, demyelination shown by Luxol fast blue, macrophage appearance by KiM1P or CD68, damage to the axons shown by Bielschowsky stain, astrocytopathy shown by glial fibrillary acidic protein, and different lymphocyte subtypes, reacting to CD3, CD4, CD8, CD20 and CD138.[7]

The sensitivity of McDonald criteria is low with regard to pathologically defined MS because around 25% of MS cases are silent MS cases.[8]

McDonald criteria have been shown to have a low sensitivity and specificity (with respect to the pathological presence of lesions) in Asiatic populations.[9][10] They have good predictive quality (with respect to CIS [clinically isolated syndrome] to CDMS [Clinically Definite Multiple Sclerosis] conversion) when evaluated in non-selected populations.[11]

2010 Revisions[edit]

In 2010, the International Panel on Diagnosis of MS met in Dublin, Ireland for a third time to discuss and revise the McDonald diagnostic criteria.[2] Reasons for revisions to the criteria included the simplification of demonstration of CNS lesions in space and time via imaging, and to address criticisms that the previous criteria did not appropriately apply to Asian populations.[2]

One study has suggested that the new criteria allow a faster diagnosis, but with slight sacrifice in accuracy.[12]

Revised Diagnostic Criteria (2010)[edit]

Clinical Presentation Additional Data Needed
* 2 or more attacks (relapses)
* 2 or more objective clinical lesions
None; clinical evidence will suffice (additional evidence desirable but must be consistent with MS)
* 2 or more attacks
* 1 objective clinical lesion
Dissemination in space, demonstrated by:
* MRI
* or further clinical attack involving different site.
New criteria: Dissemination in Space (DIS) can be demonstrated by the presence of 1 or more T2 lesions in at least 2 of 4 of the following areas of the CNS: Periventricular, Juxtacortical, Infratentorial, or Spinal Cord.
* 1 attack
* 2 or more objective clinical lesions
Dissemination in time (DIT), demonstrated by:
* MRI
* or second clinical attack
New criteria: No longer a need to have separate MRIs run; Dissemination in time, demonstrated by: Simultaneous presence of asymptomatic gadolinium-enhancing

and nonenhancing lesions at any time; or A new T2 and/or gadolinium-enhancing lesion(s) on follow-up MRI, irrespective of its timing with reference to a baseline scan; or Await a second clinical attack. [This allows for quicker diagnosis without sacrificing specificity, while improving sensitivity.]

* 1 attack
* 1 objective clinical lesion
(clinically isolated syndrome)
New criteria: Dissemination in space and time, demonstrated by:

For DIS: 1 or more T2 lesion in at least 2 of 4 MS-typical regions of the CNS (periventricular, juxtacortical, infratentorial, or spinal cord); or Await a second clinical attack implicating a different CNS site; and For DIT: Simultaneous presence of asymptomatic gadolinium-enhancing and nonenhancing lesions at any time; or A new T2 and/or gadolinium-enhancing lesion(s) on follow-up MRI, irrespective of its timing with reference to a baseline scan; or Await a second clinical attack.

Insidious neurological progression
suggestive of MS
(primary progressive MS)
New criteria: One year of disease progression (retrospectively or prospectively determined) and

two or three of the following:
1. Evidence for DIS in the brain based on 1 or more T2 lesions in the MS-characteristic (periventricular, juxtacortical, or infratentorial) regions
2. Evidence for DIS in the spinal cord based on 2 or more T2 lesions in the cord
3. Positive CSF (isoelectric focusing evidence of oligoclonal bands and/or elevated IgG index)

Future directions[edit]

Improvements in Imaging technology:

The European group MAGNIMS periodically publishes guidelines for using MRI in the diagnosis of MS that are updated as MRI technology evolves.[13][third-party source needed] Moreover, new MRI techniques, such as double inversion recovery imaging or phase sensitive inversion recovery, can be used to identify more lesions in MS which, if further validated, could be included in future criteria. Another promising MRI technique is magnetic transfer imaging, which will allow the detection of damage in normal-appearing brain tissue away from focal lesions. Finally, high resolution spectral domain optical coherence tomography could prove to be a very promising and sensitive way of identifying optic neuritis in the future.[4]

Improvements in Biomarkers:

Four biomarkers were identified for further study by the 2010 revisions of McDonal's Criteria: The CSF,[14] the serum anti-GAGA4[15] and protein signatures[16] and finally the circulating microRNA[17]

Addressing subclinical disease:

Another issue of great clinical significance that is not addressed by 2010 McDonalds criteria is subclinical disease. There are some patients who were incidentally found to have brain lesions with appearance and location consistent with MS who are now classified as having a radiologically isolated syndrome (RIS). Some of these people will develop MS even after several years. Because early initiation of MS disease-modifying therapy is associated with better clinical outcomes, it is important to identify individuals in the subclinical stage of disease and determine if initiation of treatment at this stage is beneficial. More research is currently being conducted to clarify this issue and address which RIS patients will progress to definite MS. Depending on the findings of this research, future criteria might address this controversial but highly important issue of MS care.[4]

References[edit]

  1. ^ a b Polman, CH; Reingold, SC; Edan, G; Filippi, M; Hartung, HP; Kappos, L; Lublin, FD; Metz, LM; McFarland, HF; O'Connor, PW; Sandberg-Wollheim, M; Thompson, AJ; Weinshenker, BG; Wolinsky, JS (December 2005). "Diagnostic criteria for multiple sclerosis: 2005 revisions to the "McDonald Criteria".". Annals of Neurology. 58 (6): 840–6. doi:10.1002/ana.20703. PMID 16283615. 
  2. ^ a b c Polman, CH; Reingold, SC; Banwell, B; Clanet, M; Cohen, JA; Filippi, M; Fujihara, K; Havrdova, E; Hutchinson, M; Kappos, L; Lublin, FD; Montalban, X; O'Connor, P; Sandberg-Wollheim, M; Thompson, AJ; Waubant, E; Weinshenker, B; Wolinsky, JS (February 2011). "Diagnostic criteria for multiple sclerosis: 2010 revisions to the McDonald criteria.". Annals of Neurology. 69 (2): 292–302. doi:10.1002/ana.22366. PMC 3084507Freely accessible. PMID 21387374. 
  3. ^ a b c McDonald WI, Compston A, Edan G, et al. (2001). "Recommended diagnostic criteria for multiple sclerosis: guidelines from the International Panel on the diagnosis of multiple sclerosis" (PDF). Ann. Neurol. 50 (1): 121–7. doi:10.1002/ana.1032. PMID 11456302. 
  4. ^ a b c d Ntranos, Achilles; Lublin, Fred (2016-08-22). "Diagnostic Criteria, Classification and Treatment Goals in Multiple Sclerosis: The Chronicles of Time and Space". Current Neurology and Neuroscience Reports. 16 (10): 90. doi:10.1007/s11910-016-0688-8. ISSN 1528-4042. 
  5. ^ Lassmann Hans (2010). "Acute disseminated encephalomyelitis and multiple sclerosis". Brain. 133: 317–319. doi:10.1093/brain/awp342. PMID 20129937. 
  6. ^ Miller DH, Weinshenker BG, Filippi M, Banwell BL, Cohen JA, Freedman MS, Galetta SL, Hutchinson M, Johnson RT, Kappos L, Kira J, Lublin FD, McFarland HF, Montalban X, Panitch H, Richert JR, Reingold SC, Polman CH (2008). "Differential diagnosis of suspected multiple sclerosis: a consensus approach". Mult Scler. 14: 1157–1174. doi:10.1177/1352458508096878. PMC 2850590Freely accessible. PMID 18805839. 
  7. ^ Popescu, BF; Pirko, I; Lucchinetti, CF (August 2013). "Pathology of multiple sclerosis: where do we stand?". Continuum (Minneapolis, Minn.). 19 (4 Multiple Sclerosis): 901–21. doi:10.1212/01.CON.0000433291.23091.65. PMC 3915566Freely accessible. PMID 23917093. 
  8. ^ Engell T (May 1989). "A clinical patho-anatomical study of clinically silent multiple sclerosis". Acta Neurol Scand. 79 (5): 428–30. doi:10.1111/j.1600-0404.1989.tb03811.x. PMID 2741673. 
  9. ^ HT Chong et al (2006) Proposed modifications to McDonald diagnostic criteria for Asians with multiple sclerosis, Neurology Asia 11:87–90
  10. ^ Chong, H; Kira, J; Tsai, C; Ong, B; Li, P; Kermode, A; Tan, C (19 June 2009). "Proposed modifications to the McDonald criteria for use in Asia". Multiple Sclerosis. 15 (7): 887–888. doi:10.1177/1352458509104587. 
  11. ^ Fortini, Alexandre S.; Sanders, Elizabeth L.; Weinshenker, Brian G.; Katzmann, Jerry A. (1 November 2003). "Cerebrospinal Fluid Oligoclonal Bands in the Diagnosis of Multiple Sclerosis Isoelectric Focusing With IgG Immunoblotting Compared With High-Resolution Agarose Gel Electrophoresis and Cerebrospinal Fluid IgG Index". American Journal of Clinical Pathology. 120 (5): 672–675. doi:10.1309/Y5VFF2UAW0RK5W63. PMID 14608891. 
  12. ^ Runia, TF; Jafari, N; Hintzen, RQ (Dec 2013). "Application of the 2010 revised criteria for the diagnosis of multiple sclerosis to patients with clinically isolated syndromes.". European Journal of Neurology. 20 (12): 1510–6. doi:10.1111/ene.12243. PMID 23906114. 
  13. ^ Massimo Filippi et al. MRI criteria for the diagnosis of multiple sclerosis: MAGNIMS consensus guidelines, The Lancet Neurology, Volume 15, Issue 3, March 2016, Pages 292–303
  14. ^ Awad A, Hemmer B, Hartung HP, et al. Analysis of cerebrospinal fluid in the diagnosis and monitoring of multiple sclerosis. J Neuroimmunol. 2010;219:1–7.
  15. ^ Brettschneider J, Jaskowski TD, Tumani H, et al. Serum anti-GAGA4 IgM antibodies differentiate relapsing remitting and secondary progressive multiple sclerosis from primary progressive multiple sclerosis and other neurological diseases. J Neuroimmunol. 2009;217:95–101.
  16. ^ Quintana FJ, Farez MF, Viglietta V, et al. (2008). "Antigen microarrays identify unique serum autoantibody signatures in clinical and pathologic subtypes of multiple sclerosis". Proc Natl Acad Sci U S A. 105: 18889–18894. doi:10.1073/pnas.0806310105. PMC 2596207Freely accessible. PMID 19028871. 
  17. ^ Keller A, Leidinger P, Lange J, et al. (2009). "Multiple sclerosis: microRNA expression profiles accurately differentiate patients with relapsing-remitting disease from healthy controls". PLOS ONE. 4: e7440. doi:10.1371/journal.pone.0007440.